MEDICARE: KENT B WHITAKER PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	105103-1206	UT

General Provider Information

NPI Number	:	1487635579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENT B WHITAKER PA

Provider Business Mailing Address
First Line	:	550 E 1400 N
Second Line	:	STE R
City	:	LOGAN
State	:	UT
Zip	:	84341-2406
Country	:	US
Telephone Number	:	435-755-9484
Fax Number	:	435-755-2832

Provider Business Practice Location Address
First Line	:	550 E 1400 N
Second Line	:	SUITE R
City	:	LOGAN
State	:	UT
Zip	:	84341-2406
Country	:	US
Telephone Number	:	435-755-9484
Fax Number	:	435-755-2832

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	05/15/2008

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Directions to “ KENT B WHITAKER PA” Practice Location

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